Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60 Page 61 Page 62 Page 63 Page 64 Page 65 Page 66Several themes emerged in the 2016 guidelines. These themes are applicable to both patients having and not having multiple sclerosis. First, opioid medications should not be considered first-line treatments for pain. Nonpharmacological treatments (e.g., physical therapy or exercise) and nonopioid medications (e.g., nonsteroidal anti- inflammatory medications) should always be used first. Second, when opioid medications are used, the lowest effective dose for the shortest duration of time should be prescribed. In these circumstances, immediate-release opioids are preferred to the controlled-release products. Third, patients should be made continually aware of the risks and benefits of opioid medications. Risks include side effects. (One of the most common side effects associated with opioid medications is constipation. Patients should be made aware of this side effect so that they can request treatment for constipation if it occurs.) When risk out- weighs benefits, patients should be tapered off the opioid medication. Fourth, several of the recommendations address misuse of controlled substances, including opioid medications. The misuse of controlled substances is a serious problem in the U.S. Unfortunately, people who misuse opioid medications make it harder for the people who need the medications to receive them. These guidelines suggested several practices for healthcare providers to implement so that opioid medications are not misused. By reviewing the controlled substance use history, the healthcare provider can ascertain if the need for the opioid medication is real or if the patient is just seeking opioid drugs to misuse. By requiring a urine drug test prior to prescribing an opioid medication, the healthcare provider can determine that the patient is not currently taking prescription or recreational controlled substances. 60 MSFocus Summer 2016 Pain syndromes are common in patients with multiple sclerosis. Data suggests that approximately one-half of patients with multiple sclerosis experience chronic pain. It is important to understand that not all pain caused from multiple sclerosis can be treated with opioid medications. • Neuropathic pain is the most commonly reported type of pain experienced by people with MS. It is caused from the demyelination of nerves that is the hallmark of multiple sclerosis. People describe neuropathic pain as burning, aching, or electric pain. Neuropathic pain primarily affects the legs and feet, but can also affect the trunk and arms. Data suggests that anticonvulsant medications and antidepressant medications are the best treatment for neuropathic pain. Opioid medications are not effective in treating neuropathic pain. • Spasticity, which is also common in MS patients, results from muscle cramps and spasms. Antispasticity medications and stretching exercises are the treatments of choice for pain secondary to spasticity. Opioid medications are not effective in treating pain secondary to spasticity. • Musculoskeletal pain (or non-neuropathic pain) can occur in patients with or without multiple sclerosis. It is most often caused by an injury to the bones, joints, muscles, tendons, or ligaments from events such as jerking movements, car accidents, falls, fractures, sprains, and or dislocations. Opioid medications are sometimes used to treat musculoskeletal pain.